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Director, Compliance, Santa Barbara, CA

CenCal Health


Santa Barbara, CA

May 11, 2017

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Director, Compliance

Santa Barbara, CA, US

Worker Category: Regular Full-Time

Job Class Senior Management

Job Summary (General Overview, reporting to, work environment)

Under direction from the Chief Executive Officer, the Director of Compliance serves as the Plan’s primary executor and administrator of the Plan’s compliance program. The Director’s primary function requires managerial leadership in effectively enforcing company-wide policies and procedures as they relate to federal, state and local regulations governing the practices and procedures regarding CenCal Health. The Director is responsible for compliance with all regulatory requirements, contract requirements and for conducting, coordinating and reporting audit and investigative activities for the purpose of preventing and detecting fraud, abuse and waste.

Duties and Responsibilities

  • Serves as the primary CMS compliance contact and the person responsible for ensuring overall compliance with Medi-Cal/Medicare compliance requirements. Act as liaison and contact point for all federal and state regulators
  • Coordinates and communicates to internal departments and external vendors, where appropriate all Medi-Cal/Medicare compliance activities and programs as well as plans, implements and monitors the organization’s Medicare compliance program.
  • Review all proposed legislation and regulations and ensure implementation of changes in law and regulation at the operation level
  • Oversee and coordinate all CenCal Health audits by regulatory agencies, including scheduling prep meetings, reviewing documentation to be used and ensure appropriate visibility
  • Oversee and coordinate all CenCal Health Corrective Action Plans (CAP) for submission to regulatory entities
  • Develop and implement policies and procedures to prevent and detect fraud and abuse, address specific areas of suspected fraud and abuse and initiating a corrective action plan
  • Report all suspected fraud and abuse to DHS and work with legal counsel and certified fraud investigators on fraud investigative activities and corrective actions
  • Develop and maintain strategic relationships with regulatory agencies and key constituents relative to Regulatory Submissions, Audits and Corrective Action Plans, Delegation Oversight, Regulatory Review and Analysis
  • Communicate current state of legislative issues to management and the commission recommending the organizations position. Make presentations to the Board of Directors and Executive team on status of legislative information
  • Work collaboratively with internal auditors and reviews to ensure compliance with established policies, plans, procedures and performance standards
  • Responsible for organizational compliance with CMS transmittals, HPMS notices, uploading of Medi-Cal/Medicare applications, bid submissions, submissions of sales events and Parts C and D reporting data in HPMS, material review and submissions, marketing submissions including code management, and tracks dates and deliverables to ensure that deadlines are, as well as all CMS audits and producing corrective action plans as necessary
  • Prepare monthly and/or quarterly compliance summaries for the organization
  • Other duties or projects as assigned

Skills/Knowledge/Abilities (Indicate Required or Desired)

  • Knowledge of principles and techniques of administration, organization and management including in-depth understanding of the key issues that exist in the health care industry and managing a public agency
  • Public relations in a governmental setting and trends in the health care industry
  • Local, regional, state and federal laws, ordinances, regulations, codes, precedents, government regulations, executive orders and agency rules as they relate to managed care, Medicare/Medi-Cal and other related business and polices
  • Maintain confidentiality, communicate effectively with CenCal Health staff, providers, regulatory agencies and legal counsel
  • Excellent written and verbal communication skills

Education and Experience

  • Bachelor’s degree from an accredited school or equivalent required
  • Master’s degree in business administration preferred
  • Five to nine (5-9) years of leadership and ability to direct department personnel at all levels
  • Four (4) years’ experience in health care related field
  • Managed care experience with significant accounting and auditing experience desired

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